TREATMENT OF AN ACUTE DEEP HAND BURN IN A LOW

Annals of Burns and Fire Disasters - vol. XXIX - n. 3 - September 2016
TREATMENT OF AN ACUTE DEEP HAND BURN IN A LOWINCOME COUNTRY WITH NO AVAILABLE MICROSURGERY: A
CASE REPORT
TRAITEMENT D’UNE BRÛLURE RÉCENTE ET PROFONDE DE LA MAIN DANS
UN PAYS EN VOIE DE DÉVELOPPEMENT, SANS TECHNIQUE MICRO
CHIRURGICALE POSSIBLE: À PROPOS D’UN CAS
Amouzou K.S.,1* El Harti A.,2 Kouevi-Koko T.E.,1 Abalo A.,3 Dossim A.3
1
2
3
Unité des Brûlés et des Plaies et Cicatrisations, CHU Sylvanus Olympio, Lomé, Togo
Centre National des Brûlés et Chirurgie Plastique, CHU Ibn Rochd, Casablanca, Morocco
Service de Traumatologie Orthopédie, CHU Sylvanus Olympio, Lomé, Togo
SUMMARY. Deep hand burns usually lead to joint and tendon exposure. A simple skin graft is insufficient to achieve healing. Soft tissue
reconstruction represents a surgical challenge that ranges from the simplest to the most complex flaps. In some areas, microsurgery is not
technically possible. Choice is then limited to pedicled distant flaps such as the abdominal wall flap-graft. We report a case of an acute
burned hand with exposure of metacarpophalangeal joints from the second to the fourth radius as well as proximal inter phalangeal joints
from the second to the fifth radius and extensor tendons, treated in the burns and wound care unit of the Sylvanus Olympio Teaching
Hospital in Lomé. The dorsum hand and fingers were covered with a pedicled abdominal flap-graft that was severed in two stages at 22
and 29 days. We achieved good results (sensitivity S3+, useful aesthetic hand) at two-year follow up.
Keywords: hand, burn, flap, graft, Africa
RÉSUMÉ. Les brûlures profondes de la main conduisent habituellement à une exposition articulaire et tendineuse. La reconstruction des
parties molles représente un challenge chirurgical qui va de la technique la plus simple au lambeau le plus complexe. Dans certaines
contrées, la microchirurgie n’est pas techniquement possible et le choix se limite à l’utilisation de lambeau pédiculé à distance, comme le
lambeau-greffe abdominal; nous rapportons un cas de brûlure récente de la main avec exposition des articulations métacarpo phalangiennes
du second au quatrième rayon avec de plus une atteinte des articulations inter phalangiennes proximales du second jusqu’au cinquième
rayon et exposition des tendons extenseurs. Ce patient a été pris en charge dans l'Unité des brûlés et des Plaies et Cicatrisation du Centre
Hospitalier Universitaire Sylvanus Olympio de Lomé. La face dorsale de la main et des doigts a été couverte par un lambeau-greffe pédiculé
abdominal, qui fut sevré en 2 étapes (22ème et 29ème jour). Nous avons obtenu de bons résultats sur le plan de la sensibilité ainsi que sur
l’aspect esthétique chez ce patient après deux ans de suivi.
Mots-clés: main, brûlures, lambeau, greffe, Afrique
Introduction
Deep burns on the hand frequently expose both joints and
tendons.1,2 A simple skin graft is insufficient to achieve healing.
Soft tissue reconstruction represents a surgical challenge, requiring from the simplest to the most complex flaps.2,3,4,5 When
the forearm is involved in the burn, the possibility to use locoregional flaps is limited. Distant free or pedicled flaps may
be necessary.2,3,4,5 In some areas, microsurgery is not technically possible and reconstruction is then restricted to pedicled
distant flaps, such as the abdominal wall flap.
The abdominal wall pocket is a distant flap technique in
which a subcutaneous pocket is surgically created for the injured hand, with a view to restoring skin coverage of the dor-
*
sum or palm.6,7 In 1965, Colson and Janvier described immediate and total debulking of distant flaps and called them ‘flapgrafts’. The donor site was the contralateral arm.8 To minimise
donor site morbidity and improve cosmetic outcomes, the abdominal wall is now the preferred donor site.1,5,9,10
We evaluated the functional and cosmetic outcome of a
deeply burned hand treated with an abdominal wall flap-graft
at two-year follow up.
Case report
A 43-year-old, right-handed tailor was burned on the right
forearm and hand in a domestic fire accident. The patient was
initially admitted to the intensive care unit of the Sylvanus
Corresponding author: Komla Sena Amouzou, 02BP20752, Poste 1424, Lomé, Togo. Tel.: +228 22212501; fax: +228 22259821; email: [email protected].
Manuscript: submitted 15/05/2016, accepted 21/06/2016.
228
Annals of Burns and Fire Disasters - vol. XXIX - n. 3 - September 2016
Fig. 1 - a. Deep hand and forearm burn with exposure of metacarpophalangeal joints, proximal interphalangeal joints and tendons; b. Split thickness skin graft on the forearm and abdominal wall flap, splinting fingers
with hypodermic needles; c. The hand in the abdominal wall flap.
Fig. 2 - a. The abdominal thin wall flap divided, fingers kept syndactilised;
b. Digit separation.
the second to the fourth digits, and the proximal inter phalangeal joints and extensor tendons were exposed from the second to the fifth digits (Fig. 1).
Patient consent was obtained for an abdominal wall flapgraft. Under general anaesthesia, debridement was completed.
The second to the fifth digits were splinted with long green hypodermic needles. The abdominal area was marked to the size
of the dorsum digit wounds and then infiltrated with saline
water. A skin incision was made, and four separated tunnels
were made on the abdominal wall using blunt dissection with
scissors. The tunnels were totally debulked and only the dermis
remained in contact with the hand wound. Thereafter, the digits
and the dorsum of the hand were put inside the tunnels. The
top of the tunnels were then sutured to the tips of the digits exiting the subcutaneous tunnels (Fig. 2).
The right forearm and wrist were grafted with autologous
thin skin grafts harvested from the thigh (Fig. 2).
Nurses in the burn and wound care unit changed the gauze
dressings and bandages every three days.
After 22 days, we divided the flap from the abdominal wall
whilst keeping the fingers syndactylised (Fig. 2). The digits
were then separated one week later (Fig. 2). The abdominal
wall donor site was grafted with autologous thin skin graft.
Shoulder and elbow physiotherapy started after the first
procedure. The wrist was mobilised after the second procedure.
Hand joint mobilisation started immediately after the digits
were separated. Wrist and finger exercises were continued for
six months.
At two-year follow up, function was reasonable. Sensitivity of the dorsum of the hand was S3+ on the British Medical
Research Council scale. The patient recovered a useful discriminatory sensitivity.
The skin on the dorsum of the hand was aesthetically good
and flexible, with no significant colour change (Fig. 3). The
donor site scar was good (Fig. 3).
The patient was very satisfied and recommenced his job.
He can use scissors with his right hand (Fig. 3).
Discussion
Fig. 3 - a. The skin on the dorsum of the hand is aesthetically good, and
flexible; b. Mobility of the hand; c. Patient using scissors with his right
hand; d. Donor site scar.
Olympio Teaching Hospital in September 2013, then moved to
the burn and wound care unit. After serial debridement and
dressings, the metacarpophalangeal joints were exposed from
Many types of flap can be used to cover the dorsum of the
hand.2,3,5 Loco-regional flaps such as interosseous and radial
forearm flaps may not be possible because of burn on the forearm. Free flaps are not technically possible in our area. The inguinal groin pedicled flap is possible, although it can be
uncomfortable and often needs further surgery to thin it. The
donor site scar is less conspicuous, however.2 Besides the inguinal groin flap, the only other possibility we have is the abdominal wall flap.
Some sophisticated materials have been used in descriptions of the procedure.9,10 In our case, long hypodermic needles
were used instead of kirshner wires. They were available and
less expensive. We preferred them because of their small diameter and the fact there is no need for extra equipment to
place them.
The only problem we found with the procedure was the
long period of immobilisation (22 days), which necessitates
particular attention. In our practice, the procedure did not need
any special nursing care. Physiotherapy plays an important role
in this treatment, not only for the burned hand but also for the
shoulder and elbow which are immobilised during the 22 days
of the first part of the procedure in order to avoid shoulder
229
Annals of Burns and Fire Disasters - vol. XXIX - n. 3 - September 2016
pains, as Zhao et al. published.11 After the fingers are separated,
exercises are focused on the hand and wrist to improve hand
function. Long-term physiotherapy is important for the immobilised hand but also for the initial burn injuries. In Matsumura
et al.’s study, patients had physiotherapy for six months to one
year.4 The donor site in our patient had a good aesthetic scar
appearance, as described by other authors.1, 9
We obtained good results (sensitivity S+, useful aesthetic
hand). As Prader et al. found, the recovery of sensitivity is always lower than in the opposite hand. They also found, as we
did, that patients recover a functional level of sensitivity.10
BIBLIOGRAPHY
1. Wang F, Liu S, Qiu L, Ma B et al.: Superthin Abdominal Wall GloveLike Flap Combined With Vacuum-Assisted Closure Therapy for Soft
Tissue Reconstruction in Severely Burned Hands or With Infection.
Ann Plast Surg, 75: 603-6, 2015.
2. Voulliaume D, Mojallal A, Comparin JP, Foyatier JL: Brûlures graves
de la main et lambeaux: choix thérapeutiques et revue de la littérature.
Annales de chirurgie plastique esthétique, 50: 314-319, 2005.
3. Falcone PA, Edstrom LE: Decision making in the acute thermal hand
burn: an algorithm for treatment. Hand Clin, 6: 233-8, 1990.
4. Matsumura H, Engrau LH, Nakamura DY, Vedder NB: The use of the
Millard ‘Crane’ for deep hand burns with exposed tendons and joints.
J Burn Care Rehabil, 20: 316-319, 1999.
5. Chiummariello S, Del Torto G, Maffia R, Pataia E, Alfano C: Deep burn
of hand and forearm treated by abdominal wall flap. A case report. Ann
Ital Chir (ePub), 24: 86, June 2015. Accessed February 4, 2016.
230
Conclusion
The abdominal wall flap-graft remains a simple procedure
that permits recovery in deep acute burns on the hand with exposure of tendon or joints. This procedure can be used in lowincome countries with no microsurgical equipment. It needs
no special equipment or special nursing care, but physiotherapy
is essential because of the long period of immobilisation and
depth of the initial burn.
6. Morelli E: L’empochement. In: Tubiana R (ed): « Traité de chirurgie
de la main Tome 2 », 255-261, Masson, Paris, 1984.
7. Nutchern JG, Engray LH, Nakamura DY, Dutcher KA et al.: Treatment
of fourth degree hand burns. J Burn Care Rehabil, 16: 36-42, 1995.
8. Colson P, Janvier H: Primary and total defatting of autoplasty flaps from
a distance. Ann Chir Plast Esthet, 11: 11-20, 1966.
9. Forli A, Voulliaume D, Comparin J-P, Papalia I, Foyatier J-L: Le lambeau-greffe abdominal : intérêt pour la couverture des pertes de substance tégumentaires dorsales de la main et des doigts chez le brûlé. À
propos de six cas. Annales de chirurgie plastique esthétique, 50: 146153, 2005.
10. Prader JP, Oberlin C, Bey E: Acute deep hand burns covered by a
Pocket Flap-Graft Long-term outcome based on nine cases. Journal of
Burns and Wounds, 6: 16, 2007.
11. Zhao F, He W, Zhang G, Liu S et al.: Comparison of shoulder management strategies after stage I of fingertip skin defect repair with a random-pattern abdominal skin flap. Med Sci Monit, 21: 3042-3047, 2015.